Chapter 10
Preventing Overweight and Obesity

As a society, we can no longer afford to make poor health choices such as being physically inactive and eating an unhealthy diet; these choices have led to a tremendous obesity epidemic. As policy makers and health professionals, we must embrace small steps toward coordinated policy and environmental changes that will help Americans live longer, better, healthier lives.

—Richard H. Carmona, U.S. Surgeon General, Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity at a Glance 2005 (Atlanta, GA: Centers for Disease Control and Prevention, 2005)

Many obesity researchers and health professionals believe that the most effective way to win the war on obesity is to intensify efforts to prevent overweight and obesity among children, adolescents, and adults. They assert that over time, prevention is far more cost effective than the expenditures associated with weight-loss efforts and medical treatment of obesity-related diseases. They also observe that prevention is a preferable strategy since to date no universally effective long-term treatment consistently produces and maintains weight loss.

The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (Rockville, MD: U.S. Department of Health and Human Services, 2001) called for design and implementation of interventions to prevent and decrease overweight and obesity, both individually and collectively. It asserted that effective actions must occur at many levels and acknowledged that while individual behavioral change is at the core of all strategies to reduce overweight and obesity, to be optimally effective, efforts must not be limited to individual behavioral change.

The report recommended actions to modify group influences by initiating prevention programs targeting families, communities, employers and workers, the health-care delivery system, and the media, as well as changes in public policy. Further, the report called for concerted efforts and predicted that actions to prevent and reduce overweight and obesity would fail unless changes were made at every level of American society. Characterizing these problems as societal rather than individual, the Call to Action observed that individual behavioral change is possible only in "a supportive environment with accessible and affordable healthy food choices and opportunities for regular physical activity." The report also warned that actions aimed exclusively at individual behavioral change, that did not consider social, cultural, economic, and environmental influences, would be counterproductive, serving only to reinforce negative stereotypes, bias, and stigmatization of people who are overweight or obese.

The Call to Action promised to abide by five overarching principles to guide its recommendations about how to prevent and decrease overweight and obesity. These included:

• Promoting recognition of overweight and obesity as major public health problems
• Assisting Americans to balance healthful eating with regular physical activity to achieve and maintain a healthy body weight
• Identifying effective and culturally appropriate interventions to prevent and treat overweight and obesity
• Encouraging environmental changes to help prevent overweight and obesity
• Developing and enhancing public-private partnerships to realize important public health goals

Many public health professionals believe that environmental change and policy interventions are the most promising strategies for generating and maintaining healthy nutrition and physical activity behaviors at a population level. Environmental interventions are those actions that modify availability of, access to, pricing of, or education about, foods at the places where they are purchased. Policy interventions legislate, regulate, or, through formal or informal rules, serve to guide individual and collective behavior. Examples of environmental and policy initiatives that have met with success include:

• Increasing availability of fruits and vegetables at school and workplace cafeterias, and the addition of fresh fruit to refrigerated vending machines
• Replacing soft drinks in school vending machines with fruit juices and water
• Instituting daily physical education requirements for students
• Providing point-of-purchase nutrition information at restaurants and grocery stores to encourage healthy food choices
• Allowing workers adequate break time and a location where nursing mothers can express milk so their babies can continue to accrue the health benefits of breastfeeding even after their mothers return to work

PREVENTION EFFORTS TARGET FAMILIES, COMMUNITIES, AND SCHOOLS

Public health education, communication, and other programs aimed at families and communities were identified as the cornerstone of prevention efforts. The Call to Action put forth communication strategies and corresponding actions that may be taken to promote awareness about the effects of overweight on health and support healthy eating and physical activity. For example, the communication strategy of educating expectant parents and other community members about the protective effect of breastfeeding against the development of obesity was translated into the action of creating community environments that promote and support breastfeeding. (Children who are ever breastfed are 15%-25% less likely to become overweight, and those who are breastfed for six months or more are 20%-40% less likely.) Similarly, the communication objective to heighten consumer awareness about reasonable food and beverage portion sizes was coupled with action to encourage the food industry to provide sensible food and beverage portion sizes.

Prevention efforts were not only directed to families and communities but also to policy makers whose actions to establish social and environmental policy could support communities and families to be more physically active and consume healthier diets. Policy makers were exhorted to create more community-based obesity prevention and treatment programs for children and adults and provide demonstration grants to improve access to, and availability of, healthy affordable foods in inner cities. They also were advised to enact public policy to create and maintain safe and accessible sidewalks, walking and bicycle paths, and stairs.

In the community, schools offer ideal settings and multiple opportunities for preventing overweight and obesity by educating children about, and engaging them in, healthy eating and physical activity. To reinforce their messages concerning the importance of school physical activity and nutrition programs, schools can ensure that breakfast and lunch programs meet nutrition standards and provide food options that are low in fat, calories, and added sugars. Other ways to enact this communication strategy include offering healthy snacks in vending machines and school stores, and providing all students with quality daily physical education in order to cultivate the knowledge, attitudes, skills, behaviors, and confidence needed to be physically active for life.

Population-Based Prevention Programs Target Racial and Ethnic Minority Groups

Antronette K. Yancey and her colleagues reviewed studies of population-based interventions targeting communities composed primarily of members of racial and ethnic minorities. The investigators reported their findings in "Population-Based Interventions Engaging Communities of Color in Healthy Eating and Active Living: A Review" (Preventing Chronic Disease, vol. 1, no. 1, January 2004). They identified twenty-three interventions intended to promote healthy eating and active lifestyles aimed at African-American, Hispanic, Native American, Alaska Native, Asian, Native Hawaiian or Other Pacific Islander populations that met specific study criteria and were implemented between 1972 and 2000.

Yancey and her colleagues described several initiatives instituted during the 1970s to early 1990s that produced modest but measurable improvement in diet. For example, one program promoted reducing cholesterol and saturated fat intake via targeted print and electronic media in three semi-rural northern California towns with substantial Latino populations. Another intervention sought to engage African-American residents of public housing communities in Birmingham, Alabama, in group exercise programs. A third program cultivated regional coalitions of community-based organizations to develop fitness promotion activities such as walking clubs, cooking demonstrations and classes, aerobic exercise classes, walking trails, and health fairs.

NATIONAL INITIATIVE AIMS TO HELP AFRICAN-AMERICAN WOMEN MAINTAIN A HEALTHY WEIGHT

The review by Yancey and her colleagues also described another obesity prevention intervention, "Sisters Together: Move More, Eat Better." The national program is an initiative of the Weight-Control Information Network of the National Institute of Diabetes and Digestive and Kidney Diseases (one of the institutes of the National Institutes of Health).

The program expanded upon the success of a pilot community-awareness program conducted in three inner-city communities in Boston, Massachusetts, from 1995 to 1998. The pilot program disseminated the "Move More, Eat Better" message among African-American women aged eighteen to thirty-five via educational materials and such activities as walking groups, dance classes, and cooking demonstrations.

By 2001 the program had produced three educational brochures and had collaborated with national and local newspapers, magazines, radio stations, and consumer and professional organizations to continue to increase awareness about the health benefits of regular physical activity and healthy eating. Another "Sisters Together: Move More, Eat Better" activity produced a cable television show featuring local chefs who prepared healthy menu items available in their restaurants.

To continue to spread the word about the benefits of healthy eating and regular exercise among African-American women and to encourage other groups and organizations to start comparable programs, Sisters Together expanded its promotion efforts in local communities and national media. In 2004 and 2005 Sisters Together met with magazine editors in New York City and embarked on a radio media tour in the top ten urban markets. In addition the group provided exhibits at local and national meetings and health fairs and monthly promotions to health and lifestyle reporters. Community outreach activities took the program's message to bookstores, churches, nail and hair salons, libraries, community health clinics, and historically Black colleges and universities.

Federally Funded National Nutrition Education

Together, the Department of Health and Human Services and the Department of Agriculture (USDA) update Nutrition and Your Health: Dietary Guidelines for Americans every five years. First published in 1980, the guidelines serve as the basis for federal food and nutrition education programs. Historically, some public health professionals believed that the USDA Food Pyramid was flawed because its composition was unduly influenced by pressure from the food industry, whose members know that even subtle changes to the guidelines can affect a food manufacturer's sales. Further, these public health professionals assert that the guidelines should not be expected to represent objective scientific evidence since they are developed by the U.S. government agency responsible for agriculture, rather than health.

In January 2004 members of the Dietary Guidelines Advisory Committee met to discuss the sixth version of Nutrition and Your Health: Dietary Guidelines for Americans. Among the issues the committee considered were a reassessment of the Food Guide Pyramid, the components of a healthy American diet, and energy balance. In preparation for the meeting, the thirteen committee members reviewed recent scientific research, including Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (Washington, DC: Institute of Medicine of the National Academies, 2002) and the 2003 World Health Organization (WHO) report on Diet, Nutrition and the Prevention of Chronic Diseases.

The Institute of Medicine report asserted that to meet daily energy and nutritional needs while minimizing risk for chronic disease, adults should get 45% to 65% of their calories from carbohydrates, 20% to 35% from fat, and 10% to 35% from protein. Earlier guidelines advised diets with 50% or more of carbohydrates and 30% or less of fat, with comparable protein-intake recommendations in previous and current guidelines. The guidelines for children were similar to those for adults, except that infants and younger children were advised a slightly higher proportion of fat—25% to 40% of their caloric intake. The report also emphasized balancing diet with physical activity, and recommended total daily calorie consumption for individuals based on height, weight, gender, and four different levels of physical activity. Its recommendation of an hour per day of physical activity was derived from studies of average daily energy expended by people who maintain a healthy weight.

The WHO report, produced in partnership with the Food and Agriculture Organization, called upon a team of global experts to identify new recommendations for governments on diet and exercise to combat obesity and related chronic diseases. The report advised changing daily nutritional intake and increasing energy expenditure by:

• Reducing consumption of foods high in saturated fat and sugar
• Sharply reducing the amount of salt in the diet
• Increasing the amount of fresh fruit and vegetables in the diet
• Engaging in moderate-intensity physical activity for at least an hour a day

The WHO report specifically recommended limiting fat to between 15% and 30% of total daily intake and saturated fats to less than 10% of this total. It suggested that between 55% and 75% of daily intake should be carbohydrates but that added sugars (refined or simple sugars as opposed to those naturally occurring in fruit and complex carbohydrates) should be limited to 10% or less. Protein should make up 10%-15% of calorie intake and salt should be restricted to less than 5 grams a day (about one teaspoon). In a press release dated April 23, 2003, Dr. Gro Harlem Brundtland, Director-General of the WHO, said, "Long-term progress will take time. We need to look decades ahead, and make a commitment now, to the health of our current and future generations throughout the globe. The work we are embarked upon could lead to one of the largest positive shifts in population health ever undertaken."

New Food Pyramids Debut in 2005

The new pyramid was designed in response to, "Dietary Guidelines for Americans 2005," developed by a panel of scientists and physicians and released in January 2005 by the Department of Health and Human Services and the Department of Agriculture (USDA). As the basis for revising the pyramid, the guidelines emphasize choosing complex carbohydrates over simple ones. For example, they recommend choosing bread and pasta made from whole-grain flour instead of white flour. Table 10.1 shows the difference in nutrient content between 100% whole-grain wheat flour and enriched, bleached, all-purpose white flour.

The new guidelines also stipulated the amount of saturated fat Americans should consume to keep saturated fat below 10% of their total calorie intake. (See Table 10.2.) They advise sharply limiting added sugars and choosing and preparing foods with little salt (sodium chloride) so that intake is less than 2,300 mg (approximately one teaspoon of salt) of sodium per day. Table 10.3 shows the sodium content for selected foods. It is interesting to note that processed foods that do not necessarily taste salty, such as tomato soup, nevertheless contain significant amounts of added sodium.

In April 2005 the government replaced the old single, one-size-fits-all triangular pyramid with twelve individually-tailored food pyramids and a new guide, called "MyPyramid" to help Americans improve their eating habits. Each of the pyramids is intended to meet the varying nutritional needs of people based on their ages and levels of physical activity. Table 10.4 displays the calorie requirements based on age, gender, and physical activity level calculated by the Institute of Medicine and included in the updated Dietary guidelines.

In contrast to the old pyramid, which featured horizontal bands representing food groups, the new pyramids contain rainbow-colored bands that run vertically from the tip of the pyramids to their bases. The new pyramids also have staircases climbing up one side, exhorting chronically sedentary Americans to become more active. Figure 10.1 shows the cornerstones of the new pyramid food guidance system—physical activity, variety, proportionality, moderation, gradual improvement and personalization. Further, unlike the old pyramid, the new one aims to help people control their portion sizes. The old pyramid used "serving" sizes, while the new one offers the standardized measures such as cups and ounces.

The new pyramid food guidance system delivers basic messages about healthy eating and physical activity that are nearly universally applicable. They are to:

• Eat at least 3 ounces of whole grain cereals, rice, or pasta every day.
• Choose low-fat or fat-free milk, yogurt, and other dairy products. Table 10.5 shows the differences in terms of fat and calories between full-fat and low-fat dairy products, meat, fish and baked goods.
• Choose food and beverages low in added sugars. Table 10.6 lists major sources of added sugars in the American diet.

The USDA Web site (http://www.mypyramid.gov) offers consumers the opportunity to receive customized food plans based on age, gender, and activity level. Consumers may then print personalized posters, worksheets, and other information to help them start on their healthy eating plans. In its first three months of operation, the new food pyramid Web site was visited approximately 670 million times. The revised pyramid food guidance system offers a wealth of detailed information about food intake including the number of calories people of various ages and activity levels should consume, the amounts of food to consume from different food groups, and portion size information for twelve different calorie levels, ranging from 1,000 calories to 3,200 calories per day. (See Table 10.7 and Table 10.8.)

The 2005 pyramid education plan also includes sample menus such as the 2,000 calorie food plan shown in Table 10.9 and Table 10.10 as well as Table 10.11, a food tracking chart that helps consumers monitor their intake and assess the quality of their food choices in terms of meeting their nutritional needs within the allotted calorie level.

Fans of the revised dietary guidelines and pyramids assert that even if the new pyramid and online educational resources fail to motivate Americans to change their diets and increase their activity levels, the guidelines will still have a salutary effect in terms of their influence on the food industry. For example, during 2005 food manufacturers moved to eliminate trans fats from their products and added whole grain products in response to the new government guidelines. Table 10.12 shows the major sources of trans fats in the American diet. The trans fat content of processed foods will very likely decline as food manufacturers continue to reformulate their products.

Detractors question the choice of the public relations agency hired to help create and promote the new version of the pyramid. The firm, Porter Novelli, has food companies as clients, but both Agriculture Department and agency representatives claimed there was no conflict of interest. The USDA asserts that its staff of scientists, economists, and nutritionists has neither the expertise nor the resources to promote the new pyramid food guidance system. Further, Eric Hentges, the director of the Agriculture Department's Center for Nutrition Policy and Promotion contends that without effective marketing and promotion, "we're not going to be able to get this behavior change or improve anything for Americans" (Libby Quaid, "Government Issues Twelve New Food Pyramids," Associated Press, April 19, 2005).

New Pyramid for Children

In September 2005 the USDA released "MyPyramid for Kids," a new food pyramid for children aged six to eleven, to replace the 1999 version. Like the adult pyramid, the children's pyramid displays each of the six major food groups using familiar images such as apples for fruits and bread for grains to encourage children to choose healthy foods instead burgers and fries. (See Figure 10.2.) The children's version of the pyramid features a girl running up the steps to the top and kids playing soccer, baseball and basketball, walking a dog, riding a bike, stretching, picnicking, and doing yoga.

Children are encouraged to play hard, and to get more physically active in order to meet the government's recommended sixty minutes of exercise a day. The USDA suggests that children set up home gyms, substituting items such as soup cans and stairs for weights and stair machines. Just as it does for adults, the USDA Web site provides a worksheet that allows kids to record and track their food consumption and physical activity. (See Table 10.13.)

To attract, inform, and entertain children, the USDA Web site features an interactive computer spaceship game. Players who balance food and exercise properly can blast off in an electronic spaceship to Planet Power. Choosing too many foods high in fat and sugar will cause the ship to sputter on the launch pad and release black smoke.

The MyPyramid for Kids program also employs an array of teaching materials for parents, childcare providers, and educators, including tip sheets and posters, lesson plans, CDs, Go Fish game cards, coloring books, and songs. The USDA "Team Nutrition" Web site already boasts school success stories—initiatives ranging from planting a school garden and organizing a school health fair to nutrition education programs, cooking classes, and poster contests.

Like its adult counterpart, the pyramid for kids garnered praise and criticism. In a September 28, 2005, news release, Michael Jacobson, executive director of the Center for Science in the Public Interest (CSPI), said the guidelines did not go far enough, "The materials don't even have the guts to urge kids to drink less soda pop, to eat less candy. If the government really wanted to improve kids' eating habits, it would get junk food out of schools, it would ban junk food advertising on television, it would require calorie counts on fast-food menu boards and sponsor hard-hitting educational materials. That would really drive home the point that these empty-calorie foods are causing obesity." Other consumer groups said they believed federal funds would be better spent on a mass media campaign to promote eating fruits and vegetables (Libby Quaid, "Government Unveils Food Pyramid for Kids," Associated Press, September 28, 2005).

"5-a-Day for Better Health" Program

The "5-a-Day for Better Health" program is the nation's largest public-private nutrition education initiative. The program originated in the California Department of Health Services in 1988 and is jointly sponsored by the National Cancer Institute and the Produce for Better Health Foundation (PBH), a nonprofit consumer-education foundation representing the fruit and vegetable industry. In 2001 the national 5-a-Day partnership expanded to include other voluntary health organizations and produce associations. Along with the National Cancer Institute (NCI), the lead federal agency, and PBH, the partnership now includes representatives from the USDA, CDC, American Cancer Society, Produce Marketing Association, United Fresh Fruit and Vegetable Association, National Alliance for Nutrition and Activity, and the Association of State and Territorial Directors of Health Promotion and Public Health Education.

The "5-a-Day for Better Health" program aims to increase fruit and vegetable consumption. Its objectives are "to increase public awareness of the importance of eating five or more servings of fruits and vegetables every day for better health, and to provide consumers with specific information about how to include more servings of fruits and vegetables into daily eating patterns." Data from the CDC revealed that in 2003, less than one-quarter of Americans (22.6%) ate the recommended five servings per day of fruit and vegetables. (See Figure 10.3.) Research conducted by the USDA (Biing-Hwan Lin, Jane Reed, Gary Lucier, U.S. Fruit and Vegetable Consumption: Who, What, Where, and How Much, Economic Research Service, USDA, October 2004) revealed that fruit and vegetable consumption vary by geography, age, race, and ethnicity as well as whether the food is eaten at home or away from home. The researchers found that:

• Older adults (age sixty-five and over) eat fewer French fries and potato chips than toddlers; however, older adults eat more fresh and canned potatoes than younger consumers.
• Toddlers like to eat apples, fresh and processed, while adults aged twenty to fifty-nine eat the fewest apples.
• Women aged forty and older eat the most spinach, while teenage girls eat the least.

• High-income consumers drink more orange juice, while low-income consumers drink more orange drinks (less than 10% juice).
• Consumption of French fries does not vary by income.
• Compared with low-income consumers, high-income consumers eat more of many vegetables, including fresh garlic, celery, cucumbers, bell peppers, mushrooms, and tomatoes.
• Eighty-eight percent of French fires are eaten away from home; fast food venues account for 67%.
• About 60% of catsup is consumed away from home, and fast food outlets account for one-third.
• African-American consumers, though just 13% of the U.S. population, account for 21% of sweet potato consumption. Puerto Rican Hispanics consume as many sweet potatoes as black consumers.
• White and Hispanic consumers eat more bell peppers than African-Americans and Asians. Blacks eat one-third less per capita than others.
• Per capita spinach consumption is highest among Asians.
• Hispanics consume three times more dry beans per capita than the national average.
• Consumers in the South eat more fresh cabbage than consumers in other regions.
• Watermelon consumption is greatest in the West.
• Consumers purchase sweet corn as fresh, frozen, or canned, in nearly equal proportions.
• Processed tomato products account for 80% of total tomato consumption. The largest use of tomatoes is for sauces, followed by tomato paste, canned whole tomato products, catsup, and juice.

The "5-a-Day for Better Health" program provides customized, age-appropriate health education materials for children such as lesson plans and activity sheets. "There's a Rainbow on My Plate" is a comprehensive nutrition education curriculum that encourages kindergarten through sixth grade students to develop healthy eating habits. The curriculum was designed by PBH, Dole Food Company, Inc., and Crayola®, and in 2003 placed second in PROMO Magazine's 2003 National Pro Awards in the category of the Most Innovative Communication Strategy. "There's a Rainbow on My Plate" debuted in March 2003 in 3,000 supermarkets and 12,000 elementary schools in the United States. Lessons featured information about fresh, dried, frozen, and canned fruits and vegetables and 100% fruit juices as well as the locations of these foods in the supermarket, and definitions of serving sizes. Participating schools received teacher's guides with lesson plans and activity sheets, coloring

books, packs of crayons, and take-home flyers for parents with Dole coupons.

Nutrition research has revealed that active men should consume even more than the five servings of fruit and vegetables the program has promoted since its inception. In 2000 the "5-a-Day for Better Health" program launched "Men Shoot for 9" to encourage men to eat nine servings of fruits and vegetables every day. Along with reducing risk for heart disease, high blood pressure, stroke, many cancers, and diabetes, diets rich in fruits and vegetables can help to prevent overweight and obesity. Fruits and vegetables are naturally low in calories and fat, and their high water and fiber content produce feelings of fullness and satiety. Combined with an active lifestyle and low-fat diet, eating greater amounts of fruits and vegetables and fewer high-calorie foods at meals can help control weight. The "Men Shoot for 9" program teaches men that they can feel full and consume fewer calories when they substitute vegetables for foods that contain more fat and calories.

September 2005 was designated "National 5-a-Day Month" and the Produce for Better Health Foundation and the National 5-a-Day Partnership encouraged participation in the program by issuing 5-a-Day recipes to help people readily incorporate produce into their diets, as well as worksite nutrition programs to help employers educate workers and create environments that offer increased choices for fruits and vegetables.

State Funding for Prevention Efforts

The CDC Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases aims to help states prevent obesity and other chronic diseases by focusing on poor nutrition and inadequate physical activity. The program supports states to develop and implement nutrition and physical activity interventions. The program sponsors initiatives to help populations balance caloric intake and expenditure, increase physical activity, improve nutrition by increasing consumption of fruits and vegetables, reduce television time, and increase breastfeeding.

In 2005–06, twenty-one states were funded at $400,000 to $450,000 for capacity building—state health departments are gathering data, building partnerships, and creating statewide health plans. Essentially, capacity building lays the necessary groundwork upon which to institute nutrition and physical activity interventions. In addition, seven states were funded at $750,000 to $1.3 million for basic implementation, bringing the total number of states that received funding to twenty-eight. Figure 10.4 shows the states funded for basic implementation and those that received funds for capacity building.

IS NUTRITION EDUCATION WORKING TO IMPROVE AMERICANS' DIETS?

In August 2002 NPD Foodworld reported that the Healthy Eating Index (HEI), a measure developed in 1990 by the USDA to assess the health value of Americans' diets, was the lowest it had been since 1998. The HEI is a summary measure of overall diet quality. It captures the type and quantity of foods people eat and the degree to which diets comply with specific recommendations in the USDA Dietary Guidelines and the Food Guide Pyramid. The HEI assigns points for eating consistently within USDA guidelines. It assesses ten dietary components—grains, vegetables, fruits, milk, meat, total fat, total saturated fat, cholesterol, sodium, and a varied diet—on a scale of zero to ten. Individuals who eat

grains, vegetables, fruits, milk, meat (including chicken and fish), as well as a variety of foods at or above the USDA recommended levels receive a maximum score often. A score of zero is assigned when the recommended amount of those components is not eaten. For fat, saturated fat, cholesterol, and sodium, a score of ten is awarded for eating the recommended amount or less. The highest possible score is a hundred, and a score of eighty or above is considered a healthy diet, scores between fifty-one and eighty show a need for dietary improvement, and scores below fifty indicate poor diets.

Still, some evidence indicates that Americans' food purchasing and eating habits were changing. In November 2004 the market research firm NPD Group reported that the top five items adults look for on nutrition labels were:

• Total fat
• Total calories

• Sugar
• Total carbohydrates
• Calories from fat

Harry Balzer, NPD Foodworld vice president, named the resurgence of interest in slow cooking using a crockpot, increased consumption of fried chicken, decreased coffee consumption, increased milk sales by fast food outlets, and consumers expressing a preference for salads but purchasing burgers, as the biggest surprises of the 2004 food industry survey ("The Dieting Monitor/Consumer Information," NPD Insights, January 2005).

The NPD Group's 20th Annual Eating Patterns in America report, released in October 2005, examined what consumers are eating, where they buy their food and beverages, who prepares meals, the most popular foods at each meal, and which appliances are used in meal preparation. The survey's key findings include comparisons with consumption patterns from the mid-1980s:

• In 2005, 53% of people said they try to avoid snacking, compared with 71% in 1985.
• The annual number of main meals skipped per person rose from 102 in 1985 to 114 in 2005.
• Americans are using stovetops less (down 18% from 1985), and microwave ovens more—microwave use doubled from 10% in 1985 to 20% in 2005.
• Americans were significantly more accepting of people who were overweight in 2005 than they were in 1985. In 1985, 55% of respondents completely agreed with the statement, "People who are not overweight look a lot more attractive." In 2005 just 24% completely agree with the same statement.
• Consumer concerns have changed from reducing sodium intake in 1985, to eliminating trans fat from their diets in 2005.
• In 2004, 75% of adults said they were trying to cut down or eliminate fat from their diet, and 61% said they were trying to add more whole grains.
• The use of fresh products in main meals at home decreased in 2005 compared to 1985. In 1985, 56% of in-home main meals included a fresh product. In 2005, 46% of in-home main meals included a fresh product.

• Americans are more likely to see carbonated soft drinks included at all meal occasions, and less likely to see toast.

Americans' Snack Food Choices

In January 2004 the NPD Group released its first-ever study about Americans' snack food choices Snacking in America. The report found that such salty snacks as pretzels, chips, and tortilla chips account for about a quarter of the convenience foods Americans choose for snacks. Although children and teens snack on sugary treats such as candy, gum, chewy fruit snacks, and breath mints, which accounted for an additional 14% of snack food choices, some of the fastest growing snack foods among children and adolescents aged two to eighteen are healthier choices. Yogurt is the fastest growing snack food in terms of consumption frequency among children under thirteen years old. On average, children under thirteen ate yogurt eleven more times in the year ending June 2003 than they did three years earlier. Children aged two to seven ate yogurt as a snack nearly fourteen times more often in 2003 than they did in 1999, and children aged eight to twelve snacked on yogurt 8.5 times more in 2003 than five years earlier. Although children may be making some healthier choices when it comes to snacks, they also are snacking more frequently—in 2003 children and teens consumed about twenty-two more snacks per person per year than reported in 1999.

In June 2005, the NPD group reported that fruit was the number one snack food consumed by children aged two to twelve. Consumed more often than any other snack food, among boys aged two to seven, fresh fruit was followed by yogurt, potato chips, chocolate candy, and cookies. Girls the same age ranked fresh fruit first followed by yogurt, gum, potato chips, and chocolate candy. Boys aged eight to twelve named fresh fruit, potato chips, gum, ice cream, and chocolate candy as their top five picks, and girls aged eight to twelve said fresh fruit, gum, potato chips, ice cream, and chocolate candy were their favorite snack foods (NPD SnackTrack®, NPD Group, June 2005).

Chewing gum was the number one snack food named by adults aged eighteen to fifty-four in 2005. The NPD Group's SnackTrack® found that age was a factor in the gum-chewing habits of Americans. While gum was a popular snack among children under thirteen years old, it did not rank as number one until the teenage years. After gum, the top ranking snack foods among men in 2005 were chocolate candy, fresh fruit, potato chips, breath/candy mints, ice cream, nuts, cookies, tortilla chips, and bars. Women said chocolate candy, fresh fruit, potato chips, breath/candy mints, ice cream, cookies, nuts, yogurt, and crackers are their choices.

Research on Interventions to Promote Healthy Weight

An independent Task Force on Community Preventive Services appointed by the CDC to evaluate of community, population, and health-care system strategies to address a variety of public health and health promotion topics is presently assessing the effectiveness of interventions to promote healthy eating and physical activity. The Task Force review of the effectiveness of population based interventions to promote healthy growth and development of children and adolescents and support healthy weights among adults, focuses on school-based strategies, worksite programs, health-care system interventions, and community-wide initiatives.

By mid-year 2005, the Task Force review had, for example, concluded that worksite programs combining nutrition and physical activity were effective and recommended them as strategies to control overweight and obesity. The Task Force also determined that more evidence is needed to determine the effectiveness of school-based programs to control overweight and obesity. Table 10.14 shows the progress of the Task Force Review as of the third quarter of 2005. It is important to remember that "insufficient evidence to determine effectiveness" does not mean that an intervention does not work, but rather indicates that additional research is needed to determine whether the intervention is effective.

PREVENTION PROGRAMS AT THE WORK SITE

Along with school-based nutrition programs and education initiatives aimed at the public-at-large, several notable obesity prevention efforts involved developing and implementing strategies to integrate physical activity and healthy food choices into routine worksite activities. Examples of such activities include incorporating planned activity breaks with music into lengthy meetings, offering healthy food choices at meetings and during breaks as well as at employee cafeterias, and hosting walking meetings.

Since more than 100 million Americans spend a large number of their waking hours at work, the work-site presents another opportunity for prevention programs. The U.S. Surgeon General's Call to Action advised moving beyond traditional workplace health education programs. It recommended more intensive and comprehensive efforts such as modifying physical and social environments, instituting policies consistent with the objective of preventing overweight and obesity, and extending worksite prevention efforts not only to employees but also to the families of employees and their communities.

Examples of worksite obesity prevention strategies include:

• Instituting flexible work hours and schedules to create opportunities for regular physical activity during the workday
• Ensuring that healthy food options are available

• Establishing worksite exercise facilities or creating incentives for employees to join local fitness centers
• Developing incentives for workers to achieve and maintain a healthy body weight
• Encouraging employers to require weight management and physical activity counseling as covered benefits in health insurance contracts
• Creating work environments that promote and support breastfeeding
• Instituting federal worksite programs promoting healthy eating and physical activity that not only can serve as models but also may be easily adapted for use in the private sector

Recent research suggests that obesity may begin at the office. W. Kerry Mummery and his colleagues examined the role of the workplace in the problem of overweight and obesity by studying the association between occupational sitting time and overweight and obesity in a sample of adults employed full-time ("Occupational Sitting Time and Overweight and Obesity in Australian Workers," American Journal of Preventive Medicine, vol. 29, no. 2, August 2005). The investigators found that the more time workers sit at their desks, the more likely they are to be overweight. Higher total daily sitting time was associated with a 68% increased risk of being overweight or obese.

Overall, men sat an average of 209 minutes while at work, twenty minutes more than the average for women. The investigators suggested that the extra twenty minutes might make a difference since they found a significant association between sitting time and overweight and obesity in male workers, but not in female workers.

The investigators asserted that encouraging workers to exercise may favorably influence a company's bottom line. "Time and productivity lost due to chronic diseases associated with overweight and obesity may make it financially worthwhile for employers to be more proactive in the health of their employees by promoting physical activity at work," they concluded.

Offices of the Future May Improve, Rather Than Imperil, Health and Fitness

In 2005 Dr. James Levine, a Mayo clinic obesity researcher who studies non-exercise activity thermogenesis (NEAT)—the calories people burn during everyday activities such as standing, walking, or even fidgeting, redesigned his office to encourage physical activity in order to burn calories. Levine noted that since it is metabolically more effective and probably easier for most people to put more NEAT into their lives to achieve and maintain healthy body weights than to seek organized exercise, the physically-active office would be a natural outgrowth of NEAT research.

Levine's office of the future holds meetings while walking laps on a track rather than sitting around a conference table eating donuts. Workers at computers walk on a treadmill rather than sit, and presentations are made standing at magnetic marker boards rather than sitting at desks or conference tables.

Levine's retrofitted office even appeals to his colleagues who already exercise regularly because they assert that standing and moving keeps them alert and focused throughout the day. Levine admits that there is pressure in his office to work while standing and to keep moving throughout the day, but he contends that this positive peer pressure is preferable to the pressure to bring unhealthy snack foods to the worksite (Steve Karnowski, "No Dozing, Doughnut at Office of Future," Associated Press, June 7, 2005).

INTENSIFYING THE PREVENTION AGENDA IN THE HEALTH-CARE SYSTEM

Interactions with health-care professionals are important opportunities to deliver powerful prevention messages. Although by no means universally effective, physicians' or other health professionals' prescriptions and recurring advice to prevent weight gain in order to prevent disease or reduce symptoms of existing disease are often powerful inducements for behavioral change. The majority of Americans have at least annual contact with a health-care professional, and if this contact includes information about the importance of weight management, then it may reinforce prevention messages received in other settings such as schools and worksites. Further, health-care professionals are instrumental in shaping public policy and can leverage their expertise and credibility to present accurate messages in the media and catalyze sweeping changes in the community at large.

Examples of strategies to expand on prevention efforts in the health-care delivery system include:

• Training health-care providers and health profession students to use effective techniques to prevent and treat overweight and obesity
• Cultivating partnerships between health-care providers, schools, faith-based groups, and other community organizations to target social and environmental causes of overweight and obesity
• Classifying obesity as a disease to enable reimbursement for prevention efforts
• Partially or fully covering weight-management services including nutrition education and physical activity programs as health plan benefits

USING THE MEDIA TO COMMUNICATE THE PREVENTION MESSAGE

The Surgeon General's Call to Action underscored the pivotal role of the media in prevention efforts. The media can communicate and educate the public about healthy behaviors and health risks associated with overweight and obesity. They can introduce and reinforce prevention messages from health-care professionals and can assist to alter attitudes and perceptions by celebrating healthy eating and physical activity.

Since 1995 the International Food Information Council has tracked media coverage of diet, nutrition, and food safety. In the first such report, Food for Thought (1995), the Council reported that the leading nutrition and food issues receiving newspaper, television, and other media coverage during the previous twelve months were: reducing fat intake, the impact of diet on disease risks, discussions of food-borne illnesses, vitamin and mineral intake, disease causation, caloric intake, antioxidants, cholesterol intake, sugar intake, and fiber intake. As obesity became a more prominent issue in the late 1990s and early 2000s, the Council reported that the number of stories about obesity skyrocketed from just 395 for the twelve-month period ending September 30, 2000, to 4,767 for the twelve months ending September 30, 2003. This increase reflected both an increasing volume of coverage as well as an increase in the number of media outlets reporting about diet, overweight, and obesity. In Food for Thought VI (2005), the Council reported that obesity was the leading topic in food and nutrition media stories during the previous year, followed by disease prevention, physical activity, weight management, disease causation, vitamin and mineral intake, fat intake, functional foods, mad cow disease, calorie intake, and biotechnology (http://ific.org/research/upload/FullReportFFTVI.pdf).

The World Health Organization cautioned about judicious use of the media to combat the obesity epidemic. In a June 26, 2003, press release, "WHO Encourages Media to Put Obesity in Perspective," Dr. Derek Yach, the WHO executive director for non-communicable diseases and mental health, asserted that the media's fixation on obesity threatens to overshadow efforts to improve global health. Yach said "Of course obesity is important but it isn't the only issue, and we wouldn't want that to be seen as the only issue." He also said he believed the WHO would oppose measures such as "fat taxes" intended to discourage consumption of high-fat foods. Yach offered that food manufacturers have expressed to the WHO their willingness to produce more healthful products, and he explained that based on recommendations from the World Bank, the WHO does not feel that manipulating taxes to modify consumption is advisable and that it could have undesirable effects.

EXPERTS TARGET CHILD OBESITYM

In April 2005 the American Heart Association (AHA) launched a new initiative aimed at combating childhood obesity. The AHA initiative provides recommendations specifically directed at the promotion of physical activity in schools. A January 2006, conference, "Obesity, Lifestyle, and Cardiovascular Disease Symposium" addressed topics ranging from the contribution of genetics, the environment, patterns and trends in portion sizes, factors affecting portion control, and the effects of macronutrients on calorie intake, to behavioral issues in children and adults. The initiative intends to equip healthcare providers with effective tools, enabling them to bring to bear the most timely behavioral research findings for their patients.

The AHA also is acting to enhance existing programs for their children such as "Choose to Move," an Internet-based program that helps individuals add activity to their daily lives and provides nutrition education, and the nutritional components of "Search Your Heart," a faith-based program that brings health information to churches nationwide. It is intensifying the educational messages on nutrition and physical activity already received each year by the four million elementary and middle school students who participate in such AHA programs as "Jump Rope for Heart" or shoot "Hoops for Heart."

The AHA is preparing a new book that will provide usable information and advice for people who need to lose weight and then maintain their healthy weight and fit lifestyle. The Heart Association also is publishing an Obesity Sourcebook in conjunction with the Robert Wood Johnson Foundation. The Sourcebook will provide the same level of solid science information to the public, health-care professionals, and policymakers that the AHA annual statistical update has provided for many years. The AHA also has undertaken collaborative efforts with the CDC, the American Cancer Society, and the American Diabetes Association. The product of this collaboration, "Everyday Choices" emphasizes eating well, exercising, remaining tobacco-free, and seeing a physician regularly to help prevent heart disease and stroke, as well as diabetes and some forms of cancer (Robert H. Eckel et al., "America's Children a Critical Time for Prevention," Circulation, vol. 111, April 19, 2005).

In a related effort, AHA president Robert Eckel, Nickelodeon Networks president Herb Scannell, Arkansas Governor Mike Huckabee, and former president Bill Clinton have joined forces to lead a ten-year campaign urging children to choose healthy foods and be more physically active. Clinton, who underwent quadruple coronary bypass surgery in September 2004 and a follow-up procedure in March 2005, appears in public service announcements and participated in a November 2005 town hall forum devoted to childhood obesity moderated by news anchor Linda Ellerbee. President Clinton explained that he became more concerned about children's weight problems after his heart surgery, and conceded that he was overweight as a child and struggled to lose weight and maintain a healthy weight throughout his life. Interviewed on Good Morning America (May 3, 2005), the former president asserted, "I think the consequences are enormous. You have the onset of adult diabetes in children now, plainly because of their eating habits, aggravated by the lack of exercise. We've got to change the eating habits of America's young people."